Average Length Of Therapy Research Articles

PSU19 Does the Novel Renal Marker NGAL (Neutrophil Gelatinase-Associated Lipocalin) Result in Cost Savings in Patients With Renal Impairment Following Cardiac Surgery?

Cardiac surgery can result in renal impairment necessitating hemofiltration (HF; dialysis) which prolongs the length of therapy (LOT), days in the intensive care unit (ICU) and is associated with an overall higher mortality. The decision to initiate HF-therapy is currently made on increased plasma creatinine levels, a relatively late marker (peaking days after a potentially reversible renal dysfunction). The novel urine marker NGAL (neutrophil-gelatinase-associated lipocalin) measures the acute structural damage and identifies the need for HF within hours with high accuracy. Based on data collected in 2005-2009, we prospectively included NGAL in an algorithm to modify the management of HF-therapy in 2010. Changes in incidence of HF and LOT, all costs associated with routine NGAL-testing and ICU stay (direct and indirect) as well as the economic impact were analysed. A total of 528 patients were operated with no statistical difference in numbers, case mix, risk scores and outcomes to the previous years. The expected number of patients with HF was 45.3 with an average LOT of 7.7 days (2005-2009). Introduction of NGAL-testing added costs of € 60.00/patient (€ 31.680/year). Although € 2047,50/day could be realized through public health refunding, the fixed associated costs were € 3249,70/patient/day [€ 892,52 for all supplies to operate the HF (Prismaflex, Gambro, Germany) and € 2357,18 for institutional ICU expenditure (incorporating personnel costs)] resulting in a deficit of € 1202,19/day with, and € 751,58 without HF operating. Using the new marker, only 32 patients required treatment with HF for a mean of 5.5 days and earlier initiation (1.1 days) in 2010 (p<0,001). A total of 41.6 days of treatment in ICU (occupancy) were avoided with savings of € 44.153,16. Routine NGAL testing and consecutive changes in management reduced the number of HF-therapies, lengths of therapy and ICU stay in our institution and proved to be cost-saving.

An Exploratory Study of Premature Termination in Child Analysis

Dropping out of psychotherapy among children and adolescent is a significant problem affecting 40–60 percent of the cases receiving outpatient care. Many factors have been investigated as possibly contributing to premature termination, but most of the findings were found to be inconsistent and contradictory throughout the literature. The present study is about premature termination in child analysis and includes an audit of the closed files from the period 1999–2003 at the Anna Freud Centre, London, and a qualitative study of five cases that were terminated prematurely. The audit confirmed that the rate of dropout from therapy, when understood to be an ending which is not agreed by all parties, at whatever stage this may be in the treatment-is around 60%. The audit also suggested that there are differences between cases that terminate prematurely or by mutual agreement in relation to gender and average length of therapy, but not in several other respects. The second part of this study, based on a thematic analysis of initial family interviews, discovered a set of themes characteristic of the assessment phase of work with families who were later to withdraw from treatment prematurely. These themes related to the parents' motivations for entering into therapy, their expectations about treatment, both in terms of its process and outcome, as well as their ability to think about feelings.

Adverse effects of systemic glucocorticosteroid therapy in infants with hemangiomas.

To evaluate the short- and long-term adverse effects of systemic glucocorticosteroid (GS) therapy in infants with hemangiomas. Retrospective chart review of infants treated with GSs for hemangiomas during a 3-year period. Tertiary care children's hospital. Of 141 patients identified with hemangiomas, 22 were treated with GSs. Minimum of 1-month GS therapy at a minimum starting dose of 0.5 mg/kg per day. Demographic and anthropometric measurements, starting dose and duration of GS therapy, subjective parental concerns, complications related to hemangioma, adjunctive treatment, and morning cortisol levels and/or results of corticotropin stimulation tests. The average starting dose was 2.23 mg/kg per day; average length of therapy was 28.1 weeks. Complaints of irritability, fussiness, or insomnia were identified in 16 patients (73%). Hypertension, defined as 3 or more episodes of systolic blood pressure higher than 105 mm Hg, was observed in 10 patients (45%). Morning cortisol levels were abnormal in 13 (87%) of the 15 patients evaluated. Low-dose corticotropin stimulation test results were abnormal in 2 of the 3 infants tested. While GS therapy for infantile hemangiomas was tolerated well overall, changes in behavior, insomnia, and gastrointestinal symptoms were common parental concerns. Hypertension and hypothalamic-pituitary-adrenal axis suppression were observed frequently. Infants undergoing long-term GS treatment of hemangiomas should be monitored carefully for these potential adverse effects.

Pediatric hemofiltration: Normocarb dialysate solution with citrate anticoagulation.

Fourteen children, newborn to 17 years of age, underwent continuous veno-venous hemofiltration with dialysis (CVVHD), using a new FDA-approved bicarbonate-based calcium-free dialysis solution (Normocarb) in combination with citrate anticoagulation. Dialysis prescription included use of the PRISMA system (Gambro, Lakewood, Colo., USA), with ACD-A (Baxter, Deerfield, Ill., USA) for anticoagulation and Normocarb (Dialysis Solution, Richmond Hills, Ontario, Canada) for dialysate. Diagnosis included 11 children with sepsis and 3 children with tumor lysis syndrome. Mean weight was 31.6+/-4.7 kg (range 3.7-62 kg) and average length of therapy was 11.4+/-3.7 days (range 6 h to 67 days). Length of circuit patency was 71.3+/-7.2 h (range 6 h to 127 h), which was influenced in part by a decision to change circuits at 72 h as per manufacturer's recommendation. No bleeding occurred. This protocol utilizes industry-manufactured CVVHD machinery with both thermic and ultrafiltration control, with an effective anticoagulation protocol, and industry-produced bicarbonate dialysate. The use of industry machinery and solutions allows for consistent industrial quality assurance standards. This potentially may decrease the cost of therapy and minimize the risk of pharmacy errors that can occur with pharmacy-made dialysis solutions.

CSF copper concentrations, blood-brain barrier function, and coeruloplasmin synthesis during the treatment of Wilson's disease.

During the treatment of four patients with cerebral manifestation of Wilson's disease, we measured the copper concentration in the cerebrospinal fluid (CSF) and serum, the serum coeruloplasmin concentration, the free copper concentration in the serum, and the albumin ratio CSF/serum (AR). These measurements were treated as indicators of the copper-related toxic effects on the brain and the blood-brain barrier (BBB). The half-life of the decrease in the CSF copper concentration during therapy was 23.5 +/- 5.78 months (mean +/- S.E.M.). The therapeutic-target-copper concentration in the CSF (mean normal concentration) is below 20 microg/l. The average length of therapy needed to normalize CSF-copper values in our patients with an average initial value of 76.25 microg/L was 47 month. During the first 10 month of treatment there was an increase in all cases of the measured disturbance in the blood-brain barrier (measured as the ratio of albumin in CSF to albumin in serum, AR). All patients showed an initial worsening of the neurological condition, on average after 1.75 +/- 0.25 months. The maximal rise in AR, from the initial values, was on average 18.4 +/- 5.08%; this maximum was reached after an average of 6.9 +/- 1.5 months. The AR normalized during therapy, indicating a reduction in toxicity in the blood-brain barrier region. The extent of the AR increases in individual patients did not correlate significantly with CSF copper half-life, serum copper half-life, the initial half-life of the reduction in the ratio (copper in serum)/(coeruloplasmin in serum), the initial copper concentration in CSF or serum, the initial free copper concentration in serum, or the initial dose of penicillamine (within the first 2 months). We conclude that the normalization of the CSF copper concentration in patients with the cerebral manifestation of Wilson's disease is a slow process, even if therapy is sufficient. The initial worsening of the neurological condition which has often been reported may be reflected in the disturbance of blood-brain barrier function, which we have measured here for the first time (using the parameter of the albumin ratio CSF/serum). Based on repeated measurements of the AR during the course of treatment it seems that the brain toxicity of mobilized copper can be assessed and the therapy adjusted.

Outcome assessment of minimizing vancomycin monitoring and dosing adjustments.

An approach to minimize monitoring of vancomycin therapy was evaluated in 120 patients, and results were compared with data from 120 patients in whom vancomycin therapy was monitored and adjusted based on serum peak and trough concentrations and traditional pharmacokinetic methods. Patients dosed by the nomogram (NM) had regimens adjusted based on actual body weight, estimated creatinine clearance, and a targeted trough concentration of 5-20 microg/ml. A single trough serum concentration was drawn only after 5 or more days of therapy. Overall, the average length of therapy was similar between groups (9.9 +/- 9.4 days NM and 8.6 +/- 7.2 days pharmacokinetic). The most common regimen for both groups was 1 g every 12 hours, although NM patients received significantly fewer grams/day (1.9 +/- 0.7 g/day) than the pharmacokinetic group (2.2 +/- 1.0 g/day, p<0.04). Patients dosed by NM also had significantly fewer regimen changes (0.63 +/- 0.96 vs pharmacokinetic 0.92 +/- 0.97, p=0.02) as well as significantly fewer serum concentrations measured/patient (1.08 +/- 1.9 vs 1.96 +/- 2.0, p=0.001). In addition, serum concentrations for NM patients were drawn later in therapy (5.4 +/- 2.5 vs 3.8 +/- 3.4 days, p=0.004). Of patients dosed by NM guidelines, 77 had trough concentrations drawn; these data were used to validate the nomogram. Seventy-two patients (94%) had trough concentrations in the target range of 5-20 microg/ml. No differences were found between groups with respect to cure, improvement, failure, or days to eradication, or with respect to nephrotoxicity. Finally, total drug cost/patient was not different between groups. A considerable cost savings to our institution was noted for patients dosed by NM compared with pharmacokinetics ($232.5 +/- 50.74 vs $403.75 +/- 70.97/mo, p=0.009) based on levels saved. Caution should be applied when generalizing our results to other patient populations.

Etiology and Risk Factors of 180 Cases of Native Valve Endocarditis: Report from a 5-Year National Prospective Survey in Slovak Republic

Risk factors, e tiology, and outcome of 180 cases of infective endocarditis (IE) in the Slovak Republic for 5 years were prospectively studied in a national survey. According to the Duke Endocarditis Service Criteria (1994), 169 cases were considered definitive and 21 possible/probable. The aortic valve was infected in 46.7%, mitral in 47.2%, and tricuspidal/pulmonary in 6.1% of cases. The majority of endocarditis cases was caused by Staphylococcus aureus and coagulase-negative staphylococci (CNS) (33.3%); only 12.2% were due to viridans streptococci; 11.7% were due to Enterococcus faecalis; 6.1% due to Haemophilus spp.; 10.1% due to other organisms; and 26.7% were culture negative. Single positive cultures of CNS were not considered clinically significant. More than 25% of 180 patients were older than 60 years. Rheumatic fever was a risk factor in 35.5%, dental surgery in 20.5%, prior cardiosurgery in 7.8%, and neoplasia in 6.7%. All patients were treated with antimicrobials (average length of therapy was 29.5 days) and 33.3% of patients also had surgery (valvular prosthesis replacement). Forty (22.2%) died, and 140 (77.8%) survived at day 60 after the diagnosis of endocarditis was made. All 40 deaths were attributable to infection. Univariate analysis comparing deaths and survivors did not show significant differences in most of the recorded risk factors between both groups, except age >60 (40.0% versus 21.4%, p < 0.05), staphylococcal etiology (55.0% versus 27.1%, p < 0.04), and antibiotic therapy <21 days (without surgery) (65.0% versus 3.6%, p < 0.01). These risk factors were significantly more frequently associated with deaths. Viridans streptococcal IE and surgical therapy in addition to antibiotics were associated with lower mortality in comparison to staphylococcal endocarditis ( p < 0.045) or to cases treated with antibiotics only ( p < 0.05). In comparison to other nationally based surveys in Europe (Greece, Croatia, France), the percentage of culture-negative endocarditis and spectrum of pathogens differed significantly.

Clinical Experience with Ketorolac in Children

To describe the use of parenteral ketorolac in a large population of children, focusing on dosing patterns, efficacy, and safety. Observational, prospective study conducted over a four-month period. A 122-bed children's medical center located within an academic medical center hospital. Children receiving ketorolac during their hospitalization. Indications for treatment, dose, dosing interval, use of a loading dose, length of therapy, efficacy (subjective response and use of concomitant therapy), and adverse effects (bleeding, gastrointestinal ulceration or vomiting, and renal dysfunction). Of 112 children evaluated, 110 received ketorolac for analgesia, and 2 were given ketorolac as an antipyretic. The children ranged in age from 6 months to 19 years. Doses of 0.5 mg/kg q6h were used for most children (range 0.17-1.0). The average length of therapy was 3.4 days (range 1-12). The most frequent reason for discontinuing ketorolac therapy was a change to oral therapy. Therapy was discontinued because of a lack of efficacy in only 2 children. Adverse reactions were unusual, with only 2 patients having bleeding potentially associated with ketorolac use. Ketorolac appears to be a safe and effective therapy for children when given in appropriate doses for a limited duration.

Evaluation of long-term triazolam use in an ambulatory Veterans Administration Medical Center population.

Triazolam is indicated for the short-term treatment of insomnia. To determine how it was being prescribed and used, we examined triazolam use in patients who had received the drug for greater than six weeks. We reviewed medical charts of 72 adult male patients from an ambulatory Veterans Administration population who had received a 30-day triazolam prescription with at least one refill. Results showed that although prescribed daily doses of triazolam were generally appropriate for the age of the patient being treated, the average length of therapy was 6.2 months. Seventy-five percent of the prescriptions had been written for a one-month supply with five refills. Neither prescriber specialty nor level of training was significantly related to length of therapy. Thirty-nine of the patients (54 percent) were available for a telephone interview to determine how the drug was actually being used and the adverse effects profile. Over 60 percent claimed to be taking the drug every night, 95 percent at the dose prescribed. Sixty-seven percent of the patients taking triazolam nightly reportedly did not sleep as well if they tried a night without the drug. Apart from effects on sleep, dizziness and confusion were the most commonly reported adverse effects. As a result of this study, automatic stop orders on discharge were implemented to limit triazolam therapy to inpatient stays. Physicians must evaluate the need for continued hypnotic therapy so that a longer-acting agent like flurazepam may be used if chronic medication is necessary.